People who inject drugs have fundamental concerns about HIV pre-exposure prophylaxis (PrEP) and the manner in which it is being promoted, according to a consultation conducted by the International Network of People who Use Drugs (INPUD). With limited availability of harm reduction services, poor access to HIV treatment and little progress on legal reform, respondents suggested that people who inject drugs have more pressing needs than PrEP. One activist commented:
“I don’t see why it can’t be part of a truly comprehensive, universally accessible package of services. But that is not the reality. So given that, it is simply not a priority.”
The only randomised study that has evaluated PrEP in people who inject drugs, conducted in Bangkok, showed a 49% reduction in infections, but the trial was clouded by controversy. The World Health Organization and the Centers for Disease Control and Prevention both recommend that PrEP should be considered for HIV prevention for all those at substantial risk for HIV, including people who inject drugs.
As little attention has been given to the views of drug users and activists on PrEP, INPUD organised three consultation events. Seventy-five people from 33 countries took part.
Respondents recognised that PrEP will be an important means of HIV prevention for some people and that people who inject drugs should be able to get hold of it.
“Of course people who use drugs have a right to access it. That’s just a question of fairness and equality.”
But participants raised several worries and concerns.
“When we consider that only 4% of people who use drugs who live with HIV have access to antivirals [sic], it seems crazy to start pumping in PrEP before antiretrovirals.”
Respondents questioned how, in a context of inadequate healthcare for drug users living with HIV, it would be appropriate or ethical to bring PrEP to scale among drug users who are HIV-negative. They noted that this lack of access to healthcare was linked to the broader environment of marginalisation and criminalisation.
Moreover, in most parts of the world, there is limited access to proven and inexpensive harm reduction interventions, such as needle and syringe programmes and opioid substitution therapy. In some settings provision is inadequate while in others it is illegal.
“One of the concerns is that… we’ve given people PrEP so we don’t need to give them access to any other harm reduction support.”
Respondents noted that participants in the Bangkok study into tenofovir PrEP were not offered needle and syringe exchange, which is illegal in Thailand. They also pointed to remarks by Gennady Onishchenko, the Chief Sanitary Inspector of the Russian Federation, stating that PrEP could serve as an alternative to opioid substitution therapy – which is illegal in Russia.
The provision of new, sterile injecting equipment has multiple important benefits (prevention of HIV, hepatitis C, bacterial infection and abscesses) whereas PrEP is only effective against HIV.
“The risk is that some governments would favour the idea of medicalising HIV prevention with a pill, rather than grappling with the broader social issues that harm reduction services acknowledge and work with. It is very narrow and straightjacketing as an approach, potentially.”
In a context of limited support for community-level or structural interventions for people who inject drugs, respondents reacted against PrEP as part of a re-medicalisation of HIV prevention. One respondent said:
“I think globally we are seeing an increasingly triumphalist biomedical rhetoric suggesting that we can resolve a problem as complex and driven by social determinants as HIV, with a pill – with simple biomedical intervention – and I find that pernicious and dangerous.”
“Biomedical solutions… [are] diverting attention away from the larger determinants of the risk environments and the reasons why particular groups have become key affected populations… What makes the risk in injecting drug use is criminalisation and the discrimination and human rights violations that come with it.”
Respondents also expressed suspicion about Gilead Sciences, the manufacturer of Truvada, the drug used for PrEP. Importantly, Gilead also produces hepatitis C drugs which are prohibitively expensive for most countries. Many drug user activists have been involved in challenging the pharmaceutical company’s policies.
A fault-line in HIV prevention
Commenting on these concerns in the journal Addictions, Andy Guise of the University of California and colleagues say that they are more than simply implementation challenges but represent a fundamental questioning of the potential role of PrEP for people who inject drugs.
PrEP has been promoted by the dominant institutions of HIV prevention, they suggest, without paying attention to community knowledge, priorities or concerns. The predominance of biomedical approaches over community perspectives reflects a ‘fault-line’ in HIV prevention, they say.
If PrEP is implemented without a comparable effort to achieve full coverage of needle and syringe programmes, opioid substitution therapy and antiretroviral therapy – or without significant progress on stigma and human rights – it is likely to fail.
“Advocates for PrEP, harm reduction and HIV prevention in general need to ensure that PrEP for PWID is introduced as part of a comprehensive harm reduction package that includes existing interventions that have been shown efficacious for decades,” Guise and colleagues say.
International Network of People who Use Drugs. Pre-Exposure Prophylaxis (PrEP) for People who Inject Drugs: Community voices on pros, cons, and concerns, 2016.
Guise A et al. ‘PrEP is not ready for our community, and our community is not ready for PrEP’: pre-exposure prophylaxis for HIV for people who inject drugs and limits to the HIV prevention response. Addictions, online ahead of print, 2016.